Health Alliance Medicare POS Basic Rx (HMO-POS) / Health ......Health Alliance Medicare POS Basic Rx...

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Health Alliance Medicare POS Basic Rx (HMO-POS) / Health Alliance Medicare POS 30 Rx (HMO-POS) / Health Alliance Medicare POS 10 Rx (HMO-POS) 2020 Summary of Benefits January 1, 2020 – December 31, 2020 Call toll-free 1-888-382-9771 daily from 8 a.m. to 8 p.m. local time. Voicemail is used on holidays and weekends from April 1 to September 30. TTY 711 healthalliancemedicare.org H1463_20_76775_M

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Page 1: Health Alliance Medicare POS Basic Rx (HMO-POS) / Health ......Health Alliance Medicare POS Basic Rx (HMO-POS) / Health Alliance Medicare POS 30 Rx (HMO-POS) / Health Alliance Medicare

Health Alliance Medicare POS Basic Rx (HMO-POS) / Health Alliance Medicare POS 30 Rx (HMO-POS) / Health Alliance Medicare POS 10 Rx (HMO-POS)

2020 Summary of Benefits

January 1, 2020 – December 31, 2020

Call toll-free 1-888-382-9771 daily from 8 a.m. to 8 p.m. local time. Voicemail is used on holidays and weekends from April 1 to September 30. TTY 711

healthalliancemedicare.org

H1463_20_76775_M

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This booklet gives you a summary of what our plans cover and what you pay. It doesn't list every service we cover or every limitation or exclusion. For a complete list of covered services, call us and ask for the Evidence of Coverage.

Options for Getting Medicare Benefits • Original Medicare (fee-for-service), which is run by the federal government • Medicare Advantage through a private company, like Health Alliance Medicare

Tips for Comparing Medicare Options This booklet allows you to compare costs and benefits for our plans. • If you want to compare our plans with other Medicare Advantage plans, ask other plans for their Summary of Benefits booklets or

use the Medicare Plan Finder at medicare.gov. • If you want to know more about the coverage and costs of Original Medicare, look in your Medicare and You handbook. You can

find it at medicare.gov. You can also get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.

Booklet Sections • Things to Know • Monthly Premium, Deductible and Limits on How Much You Pay for Covered Services • Covered Medical and Hospital Benefits • Prescription Drug Benefits • Additional Covered Benefits • About Us

This document is available in other formats, such as Braille and large print. For more information, call 1-800-965-4022 (TTY 711), daily from 8 a.m. to 8 p.m. local time. Voicemail is used on holidays and weekends from April 1 to September 30.

THINGS TO KNOW

Hours of Operation Call daily from 8 a.m. to 8 p.m. local time. Voicemail is used on holidays and weekends from April 1 to September 30.

Contact Info • If you’re a current member: 1-800-965-4022 (TTY 711) • If you’re not yet a member: 1-888-382-9771 (TTY 711) • healthalliancemedicare.org

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Eligibility To join any of our Medicare Advantage plans, you must be entitled to Medicare Part A, enrolled in Medicare Part B and live in our service area.

Our service area includes these counties in Illinois: Boone, Brown, Bureau, Carroll, Cass, Champaign, Christian, Clark, Clay, Coles, Crawford, Cumberland, De Witt, DeKalb, Douglas, Edgar, Edwards, Effingham, Fayette, Ford, Franklin, Fulton, Hancock, Henderson, Henry, Iroquois, Jackson, Jasper, Jefferson, Jo Daviess, Johnson, Kankakee, Knox, La Salle, Lawrence, Lee, Livingston, Logan, Macon, Macoupin, Marion, Marshall, Mason, McDonough, McLean, Menard, Mercer, Montgomery, Morgan, Moultrie, Ogle, Peoria, Perry, Piatt, Pike, Putnam, Richland, Rock Island, Saline, Sangamon, Schuyler, Scott, Shelby, Stark, Stephenson, Tazewell, Vermilion, Wabash, Warren, Wayne, Whiteside, Williamson, Winnebago and Woodford. Our service area includes these counties in Indiana: Fountain, Vermillion and Warren.

Doctors, Hospitals and Pharmacies Our plans have a large network of doctors, hospitals, pharmacies, and other providers to choose from.

With our POS plans, you must have a primary care provider (PCP) to oversee your care and refer you to the specialists, but you also have the flexibility to see out-of-network providers.

You must use network pharmacies to fill your prescriptions in most cases. Some of our in-network pharmacies are preferred cost-sharing pharmacies, meaning you may pay less there for some drugs.

You can see our provider directory and pharmacy directory at our website (healthalliancemedicare.org). You can call us, and we will send you a copy.

What We Cover Like all Medicare Advantage plans, we cover everything Original Medicare covers, but we also cover more.

For some benefits, you may pay less in our plan than you would in Original Medicare, and for some, you may pay more. This booklet outlines many of our extra benefits and perks that Original Medicare doesn’t cover. We cover the prescriptions drugs listed in our formulary at healthalliancemedicare.org. You can read it online or call us for a copy. Determining Drug Costs Each of the drugs we cover is grouped into one of five tiers. The amount you pay depends on the drug’s tier and what stage of the benefit you’ve reached (Initial Coverage, Coverage Gap or Catastrophic Coverage). You can find out what tier your drug is on in our formulary at healthalliancemedicare.org, and we discuss the benefit stages later in this booklet.

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Pre-Enrollment Checklist Before making an enrollment decision, it is important that you fully understand our benefits and rules. If you have any questions, you can call and speak to a customer service representative at 1-888-382-9771. Understanding the Benefits

Review the full list of benefits found in the Evidence of Coverage (EOC), especially for those services that you routinely see a doctor. Visit HealthAllianceMedicare.org or call 1-888-382-9771 to view a copy of the EOC.

Review the provider directory (or ask your doctor) to make sure the doctors you see now are in the network. If they are not listed, it means you will likely have to select a new doctor.

Review the pharmacy directory to make sure the pharmacy you use for any prescription medicines is in the network. If the pharmacy is not listed, you will likely have to select a new pharmacy for your prescriptions.

Understanding Important Rules

In addition to your monthly plan premium, you must continue to pay your Medicare Part B premium. This premium is normally taken out of your Social Security check each month.

Benefits, premiums and/or copayments/co-insurance may change on January 1, 2021.

Except in emergency or urgent situations, we do not cover services by out-of-network providers (doctors who are not listed in the provider directory).

For HMO-POS plans only: Our plan allows you to see providers outside of our network (non-contracted providers). However, while we will pay for covered services provided by a non-contracted provider, the provider must agree to treat you. Except in an emergency or urgent situations, non-contracted providers may deny care. In addition, you may pay a higher co-pay for services received by non-contracted providers.

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Health Alliance Medicare POS Basic Rx (HMO-POS)

Health Alliance Medicare POS 30 Rx (HMO-POS)

Health Alliance Medicare POS 10 Rx (HMO-POS)

MONTHLY PREMIUM, DEDUCTIBLE AND LIMITS ON HOW MUCH YOU PAY

Premium Each Month You must continue to pay your Medicare Part B premium.

$51 $100 $160

Medical Deductible $0 $0 $0

Prescription Drugs Deductible

$0 $0 $0

Maximum Out-of-Pocket Each Year The most you pay for copays, coinsurance and other costs for medical services for the year. You still need to pay your monthly premiums.

In-network providers $6,700 $5,500 $4,500

In-network and Out-of-network providers

$10,000 $10,000 $5,750

COVERED MEDICAL AND HOSPITAL BENEFITS

Inpatient Hospital Care Our plan covers an unlimited number of days for an inpatient hospital stay. (may require prior authorization)

In-network: • $450 copay per day for days 1 through 4 • $0 copay per day for days 5 and beyond

• $350 copay per day for days 1 through 5 • $0 copay per day for days 6 and beyond

• $250 copay per day for days 1 through 8 • $0 copay per day for days 9 and beyond

Out-of-network: • $600 copay per day for days 1 • $375 copay per day for days 1 25% of the cost

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through 6 • $0 copay per day for days 7 through 90

through 8 • $0 copay per day for days 9 through 60 • $200 copay per day for days 61 through 90

Ambulatory Surgical Center (may require prior authorization)

In-network: 25% of the cost $325 copay $275 copay

Out-of-network: 25% of the cost $375 copay $325 copay

Outpatient Hospital Care (may require prior authorization)

In-network: 25% of the cost $325 copay $275 copay

Out-of-network: 25% of the cost $375 copay $325 copay

DOCTOR VISITS

Primary Care Physician Office Visits

In-network: $15 copay $15 copay $20 copay

Out-of-network: $50 copay $50 copay $40 copay

Specialist Office Visits

In-network: $50 copay $45 copay $30 copay

Out-of-network: $65 copay $50 copay $40 copay

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Virtual Visits Our plan covers visits with a provider by phone or online, 24/7.

In-network: $0 copay $0 copay $0 copay

Out-of-network: $0 copay $0 copay $0 copay

Preventive Care Our plan covers many preventive services, including but not limited to: • Abdominal aortic aneurysm screening • Annual “Wellness” visit • Bone mass measurement • Breast cancer screening (mammogram) • Cardiovascular disease risk reduction visit • Cardiovascular disease testing • Cervical and vaginal cancer screening • Colorectal cancer screenings (colonoscopy, fecal occult blood test, flexible sigmoidoscopy) • Depression screening • Diabetes screenings • HIV screening • Immunizations, including Flu shots, Hepatitis B shots, Pneumococcal shots • Medical nutrition therapy • Obesity screening and therapy • Prostate cancer screenings (PSA) • Screening and counseling to reduce alcohol misuse • Screening for sexually transmitted infections (STIs) and counseling to prevent STIs • Smoking and tobacco use cessation (counseling to stop smoking or tobacco use) • “Welcome to Medicare” preventive visit (one-time)

In-network: $0 copay $0 copay $0 copay

Out-of-network: $50 copay $50 copay $30 copay

EMERGENCY SERVICES

Emergency Care If you are immediately admitted to the hospital, you do not have to pay your share of the cost for emergency care. See the “Inpatient Hospital Care” section of this booklet for other costs.

In-network: $90 copay $90 copay $90 copay

Out-of-network: $90 copay $90 copay $90 copay

Urgent Care Services

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In-network: $65 copay $40 copay $30 copay

Out-of-network: $65 copay $40 copay $30 copay

DIAGNOSTIC SERVICES Costs for these services may vary based on place of service and may require prior authorization.

Diagnostic Tests, Procedures and Lab Services

In-network: $40 copay $40 copay $0 copay

Out-of-network: $50 copay $50 copay $30 copay

Diagnostic Radiology (such as MRIs, CT scans)

In-network: $40 copay $40 copay $0 copay

Out-of-network: $50 copay $50 copay $30 copay

Outpatient X-rays (such as x-rays and ultrasounds)

In-network: $40 copay $40 copay $0 copay

Out-of-network: $50 copay $50 copay $30 copay

HEARING, DENTAL AND VISION

Diagnostic Hearing Exam (Exam to diagnose and treat hearing and balance issues)

In-network: $25 copay $25 copay $25 copay

Out-of-network: $40 copay $40 copay $40 copay

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Routine Hearing Exam (Must be with a TruHearing® provider) (Copayment is not subject to the maximum out-of-pocket) (1 exam per year)

In-network: $45 copay $45 copay $45 copay

Out-of-network: Not Covered Not Covered Not Covered

Hearing Aids Up to two TruHearing-branded hearing aids every year (one per ear per year). Benefit is limited to the TruHearing-branded® Advanced and Premium hearing aids, which come in various styles and colors. You must see a TruHearing® provider to use this benefit. Premium hearing aids are available in rechargeable style options for an additional $75 per aid. Limitations may apply. Copayment is not subject to the maximum out-of-pocket.

Hearing aid purchases include: • 3 provider visits within first year of hearing aid purchase • 45-day trial period • 3-year extended warranty • 48 batteries per aid

Advanced: (In-network) $699 copay per aid $699 copay per aid $699 copay per aid

Premium: (In-network) $999 copay per aid $999 copay per aid $999 copay per aid

Medicare-covered Comprehensive Dental Services • Extractions of teeth to prepare jaw for radiation treatment of neoplastic disease • Non-covered procedures or services (e.g. tooth

removal) if performed by a dentist incident to and as an integral part of an otherwise Medicare-covered procedure • Dental exams prior to kidney transplantation

In-network: $20 copay $20 copay $20 copay

Out-of-network: $20 copay $20 copay $20 copay

Non-Medicare-covered Dental Services (up to $200 per plan year) Including, but not limited to: oral exam, cleaning, x-rays, fluoride treatment, fillings, dentures, denture adjustments and repairs, crowns, treatment for gum disease, bridge work, root canals, and extractions. You will be responsible for any cost above the $200

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maximum benefit limit. Oral Exam, balance is

applied to $200 maximum benefit limit:

$0 copay $0 copay $0 copay

Vision Services Exam to diagnose and treat diseases and conditions of the eye.

In-network: $15 copay $15 copay $20 copay

Out-of-network: $50 copay $50 copay $40 copay

Eyewear After Cataract Surgery One pair of eyeglasses or contact lenses after each cataract surgery.

In-network: $25 copay $25 copay $25 copay

Out-of-network: $40 copay $40 copay $40 copay

Glaucoma Screening

In-network: $0 copay $0 copay $0 copay

Out-of-network: $50 copay $50 copay $30 copay

Routine Eye Exam (1 exam per plan year)

In-network: $0 copay $0 copay $0 copay

Out-of-network: Not Covered Not Covered Not Covered

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MENTAL HEALTH CARE

Outpatient Individual Mental Health Therapy Visit

In-network: $40 copay $40 copay $30 copay

Out-of-network: $50 copay $50 copay $40 copay

Outpatient Group Mental Health Therapy Visit

In-network: $40 copay $40 copay $30 copay

Out-of-network: $50 copay $50 copay $40 copay

Inpatient Mental Health Visit Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital. Our plan also covers 60 “lifetime reserve days.” These are “extra” days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. (may require prior authorization)

In-network: • $395 copay per day for days 1 through 4 • $0 copay per day for days 5 through 90

• $245 copay per day for days 1 through 6 • $0 copay per day for days 7 through 90

• $175 copay per day for days 1 through 9 • $0 copay per day for days 10 through 90

Out-of-network: • $470 copay per day for days 1 through 4 • $0 copay per day for days 5 through 90

• $275 copay per day for days 1 through 8 • $0 copay per day for days 9 through 60 • $150 copay per day for days 61 through 90

25% of the cost

SKILLED NURSING FACILITIES

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Skilled Nursing Facility (SNF) Our plan covers up to 100 days in an SNF. (may require prior authorization)

In-network: • $0 copay per day for days 1 through 20 • $178 copay per day for days 21 through 100

• $0 copay per day for days 1 through 20 • $178 copay per day for days 21 through 100

• $0 copay per day for days 1 through 20 • $178 copay per day for days 21 through 100

Out-of-network: • $100 copay per day for days 1 through 20 • $200 copay per day for days 21 through 100

• $200 copay per day for days 1 through 20 • $400 copay per day for days 21 through 100

• $85 copay per day for days 1 through 20 • $225 copay per day for days 21 through 100

PHYSICAL THERAPY

Outpatient Physical Therapy (may require prior authorization)

In-network: $40 copay $20 copay $20 copay

Out-of-network: $50 copay $50 copay $30 copay

TRANSPORTATION SERVICES

Ambulance Authorization for non-emergency transportation by ambulance is required.

In- and out-of-network emergent:

$350 copay $275 copay $275 copay

Out-of-network non-emergent:

$350 copay $275 copay $275 copay

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Transportation (within the U.S. and it’s territories)

Not Covered Not Covered Not Covered

Worldwide Emergency Transportation (outside the U.S. and it’s territories)

$350 copay $275 copay $275 copay

MEDICARE PART B DRUGS

Medicare Part B Drugs such as Chemotherapy Drugs (may require prior authorization)

In-network: 20% of the cost 20% of the cost 15% of the cost

Out-of-network: 25% of the cost 20% of the cost 25% of the cost

Other Medicare Part B Drugs (may require prior authorization)

In-network: 20% of the cost 20% of the cost 15% of the cost

Out-of-network: 25% of the cost 20% of the cost 25% of the cost

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PART D PRESCRIPTION DRUGS

You pay the following until your total yearly drug costs reach $4,020. Total yearly drug costs are the total drug costs paid by both you and our Part D plan. Once you have reached this amount, you will move to the next stage (the Coverage Gap Stage).

Costs may differ based on pharmacy type or status (e.g., preferred/non-preferred, mail order, long-term care (LTC) or home infusion, and 30 or 90 day supply. You may get your drugs at network retail pharmacies and mail-order pharmacies. If you reside in a long-term care facility, you pay the same as at a retail pharmacy.

Initial Coverage for Preferred Retail Cost-Sharing

Tier 1 - Preferred Generic

30-day supply: $0 copay $0 copay $0 copay

90-day supply: $0 copay $0 copay $0 copay

Tier 2 - Generic

30-day supply: $20 copay $20 copay $20 copay

90-day supply: $50 copay $50 copay $50 copay

Tier 3 - Preferred Brand

30-day supply: $47 copay $47 copay $47 copay

90-day supply: $117.50 copay $117.50 copay $117.50 copay

Tier 4 - Non-Preferred Drug

30-day supply: 50% of the cost 50% of the cost 50% of the cost 90-day supply: 50% of the cost 50% of the cost 50% of the cost

Tier 5 - Specialty Tier 30-day supply: 33% of the cost 33% of the cost 33% of the cost 90-day supply: 33% of the cost 33% of the cost 33% of the cost

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Initial Coverage for Standard Retail Cost-Sharing

Tier 1 - Preferred Generic

30-day supply: $12 copay $12 copay $12 copay

90-day supply: $36 copay $36 copay $36 copay

Tier 2 - Generic

30-day supply: $20 copay $20 copay $20 copay

90-day supply: $60 copay $60 copay $60 copay

Tier 3 - Preferred Brand

30-day supply: $47 copay $47 copay $47 copay

90-day supply: $141 copay $141 copay $141 copay

Tier 4 - Non-Preferred Drug

30-day supply: 50% of the cost 50% of the cost 50% of the cost 90-day supply: 50% of the cost 50% of the cost 50% of the cost

Tier 5 - Specialty Tier 30-day supply: 33% of the cost 33% of the cost 33% of the cost 90-day supply: 33% of the cost 33% of the cost 33% of the cost

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Initial Coverage for Standard Mail-Order Cost-Sharing

Tier 1 - Preferred Generic

30-day supply: $12 copay $12 copay $12 copay

90-day supply: $30 copay $30 copay $30 copay

Tier 2 - Generic

30-day supply: $20 copay $20 copay $20 copay

90-day supply: $50 copay $50 copay $50 copay

Tier 3 - Preferred Brand

30-day supply: $47 copay $47 copay $47 copay

90-day supply: $117.50 copay $117.50 copay $117.50 copay

Tier 4 - Non-Preferred Drug

30-day supply: 50% of the cost 50% of the cost 50% of the cost 90-day supply: 50% of the cost 50% of the cost 50% of the cost

Tier 5 - Specialty Tier 30-day supply: 33% of the cost 33% of the cost 33% of the cost 90-day supply: 33% of the cost 33% of the cost 33% of the cost

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Coverage Gap

Most Medicare drug plans have a coverage gap (also called the “donut hole”). This means that there’s a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $4,020. After you enter the coverage gap, you pay 25% of the plan’s cost for covered brand name drugs and 25% of the plan’s cost for covered generic drugs until your costs total $6,350, which is the end of the coverage gap. Not everyone will enter the coverage gap.

Catastrophic Coverage

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $6,350, you pay the greater of: 5% of the cost, or $3.60 copay for generic (including brand drugs treated as generic) and a $8.95 copayment for all other drugs.

ADDITIONAL BENEFITS

Acupuncture (Covered for headache, neck pain, and lower back pain) (Up to 15 visits per year)

In- and out-of-network: $15 copay $15 copay $20 copay

Chemotherapy For Part B chemotherapy drugs. (may require prior authorization)

In-network: 20% of the cost 20% of the cost 15% of the cost

Out-of-network: 25% of the cost 20% of the cost 25% of the cost

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Chiropractic Care Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position). (may require prior authorization)

In-network: $20 copay $20 copay $20 copay

Out-of-network: $50 copay $50 copay $45 copay

Durable Medical Equipment Wheelchairs, oxygen, etc. (may require prior authorization)

In-network: 0%-20% of the cost, depending on the supply

0%-20% of the cost, depending on the supply

0%-20% of the cost, depending on the supply

Out-of-network: 20% of the cost 20% of the cost 20% of the cost

Diabetes Monitoring Supplies Manufacturer (Abbott Laboratories) limitations apply only to Blood Glucose Meters and Strips, and these items have a member coinsurance of 0% in-network.

In-network: $0 copay $0 copay $0 copay

Out-of-network: 20% of the cost 20% of the cost 20% of the cost

Diabetes Self-Management Training

In-network: $0 copay $0 copay $0 copay

Out-of-network: $50 copay $50 copay $30 copay

Foot Care (Podiatry Services) Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions.

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In-network: $50 copay $45 copay $30 copay

Out-of-network: $50 copay $50 copay $40 copay

Home Health Care

In-network: $0 copay $0 copay $0 copay

Out-of-network: $50 copay $50 copay $30 copay

Hospice $0 copay for hospice care from a Medicare-certified hospice. You may have to pay part of the costs for drugs and respite care. Hospice is covered by Original Medicare. Please contact us for more details.

In-network: $0 copay $0 copay $0 copay

Outpatient Cardiac Rehabilitation Service For a maximum of two one-hour sessions per day for up to 36 sessions up to 36 weeks.

In-network: $0 copay $0 copay $0 copay

Out-of-network: $50 copay $50 copay $30 copay

Outpatient Occupational Therapy Visit (may require prior authorization)

In-network: $40 copay $20 copay $20 copay

Out-of-network: $50 copay $50 copay $30 copay

Outpatient Speech and Language Therapy Visit (may require prior authorization)

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19

Health Alliance Medicare POS Basic Rx (HMO-POS)

Health Alliance Medicare POS 30 Rx (HMO-POS)

Health Alliance Medicare POS 10 Rx (HMO-POS)

In-network: $40 copay $20 copay $20 copay

Out-of-network: $50 copay $50 copay $30 copay

Outpatient Substance Abuse Group Therapy Visit In-network: $50 copay $40 copay $30 copay

Out-of-network: $50 copay $50 copay $40 copay

Outpatient Substance Abuse Individual Therapy Visit In-network: $50 copay $40 copay $30 copay

Out-of-network: $50 copay $50 copay $40 copay

Outpatient Surgery at an Ambulatory Surgical Center (may require prior authorization)

In-network: 25% of the cost $325 copay $275 copay

Out-of-network: 25% of the cost $375 copay $325 copay

Outpatient Surgery at an Outpatient Hospital (may require prior authorization)

In-network: 25% of the cost $325 copay $275 copay

Out-of-network: 25% of the cost $375 copay $325 copay

Over-the-Counter Items

In-network: Not Covered Not Covered Not Covered

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Health Alliance Medicare POS Basic Rx (HMO-POS)

Health Alliance Medicare POS 30 Rx (HMO-POS)

Health Alliance Medicare POS 10 Rx (HMO-POS)

Out-of-network: Not Covered Not Covered Not Covered

Prosthetic Devices and Related Medical Supplies Braces, Artificial Limbs, etc. (may require prior authorization)

In-network: 20% of the cost 20% of the cost 20% of the cost

Out-of-network: 20% of the cost 20% of the cost 20% of the cost

Renal Dialysis

In-network: $0 copay $0 copay $0 copay

Out-of-network: 20% of the cost 20% of the cost 20% of the cost

Therapeutic Shoes or Inserts for Diabetics

In-network: $0 copay $0 copay $0 copay

Out-of-network: 20% of the cost 20% of the cost 20% of the cost

WELLNESS PROGRAMS

Be Fit Fitness Benefit Reimbursement for gym membership or individual fitness class fees: Up to $360/year • Can submit receipts monthly, quarterly or at the end of the year • Does not apply to out-of-pocket maximum

Wellness Rewards Program With our Wellness Rewards program, you have the opportunity to earn a $50 gift card for doing specified wellness activities.

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Health Alliance Medicare POS Basic Rx (HMO-POS)

Health Alliance Medicare POS 30 Rx (HMO-POS)

Health Alliance Medicare POS 10 Rx (HMO-POS)

Health Alliance Medicare is a Medicare Advantage Organization with a Medicare contract. Enrollment in Health Alliance Medicare depends on contract renewal. Out-of-network/non-contracted providers are under no obligation to treat Health Alliance Medicare members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services. Other Pharmacies/Physicians/Providers are available in our network. Plans may offer supplemental benefits in addition to Part C benefits and Part D benefits.

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ABOUT US Health Alliance Medicare is part of a company that has served Illinois for over 35 years. We have more than 30,000 Medicare members.

True Service with a Local Touch When you call, you speak with one of our helpful representatives, right in Champaign. They know our plans inside and out and can help you with the following.

• Answering your questions • Signing you up for a seminar • Arranging for someone to meet with you • Enrolling you over the phone

Stop by weekdays from 8:30 a.m. to 4:30 p.m. in southwest Champaign. We’re at 3301 Fields South Drive, Suite 105, right off Interstate 57 at the Curtis Road exit.

Some of Our Many Extra Perks and Programs

• Assist America global emergency services to help connect you to medical services while traveling, like helping replace lost prescriptions and getting you back home if you’re sick

• 24-hour Anytime Nurse Line to answer your health-related questions, day or night • Be Fit fitness benefit to pay you back up to $360 per year for gym membership or fitness class fees • Care coordination to help you deal with chronic conditions • Health coaching to help you set and reach your health goals

Call 1-888-382-9771 (TTY 711), daily from 8 a.m. to 8 p.m. local time. Voicemail is used on holidays and weekends from April 1 to September 30.

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D

ISCR

IMIN

AT

ION

IS AG

AIN

ST T

HE

LA

W

Health A

lliance complies w

ith applicable Federal civil rights laws and does not discrim

inate on the basis of race, color, national origin, age, disability or sex. H

ealth Alliance does not exclude people or treat them

differently because of race, color, national origin, age, disability or sex. H

ealth Alliance:

• Provides free aids and services to people w

ith disabilities to comm

unicate effectively with us, such as:

o Q

ualified sign language interpreters o

Written inform

ation in other formats (large print audio, accessible electronic form

ats, other formats)

• Provides free language services to people w

hose primary language is not English, such as:

o Q

ualified interpreters o

Information w

ritten in other languages If you need these services, contact custom

er service. If you believe that H

ealth Alliance has failed to provide these services or discrim

inated in another way on the

basis of race, color, national origin, age, disability, or sex, you can file a grievance with: H

ealth Alliance

Medicare, M

ember Services, 3310 Fields South D

rive, Cham

paign, IL 61822 or 411 N. C

helan Ave,

Wenatchee, W

A 98801, telephone for m

embers in Illinois, Indiana, Iow

a and Ohio: 1-800-965-4022;

telephone for mem

bers in Washington: 1-877-750-3350 TTY

: 711, fax: 217-902-9705, M

emberServices@

healthalliance.org. You can file a grievance in person or by m

ail, fax or email. If you need

help filing a grievance, Mem

ber Services is available to help you. You can also file a civil rights com

plaint w

ith the U.S. D

epartment of H

ealth and Hum

an Services, Office for C

ivil Rights, electronically through the

Office for Civil R

ights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by m

ail or phone at: U

.S. Departm

ent of Health and H

uman Services, 200 Independence A

venue SW, R

oom 509F,

HH

H B

uilding, Washington, D

C 20201,

1-800-368-1019, TTY: 1-800-537-7697.

Com

plaint forms are available at http://w

ww

.hhs.gov/ocr/office/file/index.html.

ATEN

CIÓ

N: Si habla Español, servicios de asistencia lingüística, de form

a gratuita, están disponibles para usted. IA

, IL, IN, O

H: Llam

e 1-800-965-4022, WA

Llame: 1-877-750-3350 (TTY

: 711). 注意:如果你講中文,語言協助服務,免費的,都可以給你。

IA, IL, IN

, OH

: 呼叫

1-800-965-4022, W

A: 呼

叫 1-877-750-3350(TTY

: 711)。

UW

AG

A: Jeśli m

ówić Polskie, usługi pom

ocy języka, bezpłatnie, są dostępne dla Ciebie. IA

, IL, IN, O

H:

Zadzwoń 1-800-965-4022, W

A: Zadzw

oń 1-877-750-3350 (TTY: 711).

Chú ý: N

ếu bạn nói Tiếng Việt, các dịch vụ hỗ trợ ngôn ngữ, m

iễn phí, có sẵn cho bạn. IA, IL, IN

, OH

: Gọi

1-800-965-4022, WA

: Gọi 1-877-750-3350 (TTY

: 711). 주의

: 당신이한국어

, 무료

언어

지원

서비스를

말하는

경우

사용할

수 있습니다

. 1-800-965-4022 IA, IL,

IN, O

H: 전화

WA

: 1-877-750-3350 전화

(TTY: 711).

ВН

ИМ

АН

ИЕ: Если вы

говорите русский, вставки услуги языковой помощ

и, бесплатно, доступны

для вас. IA, IL, IN

, OH

: Вы

зов 1-800-965-4022, WA

: Вы

зов 1-877-750-3350 (TTY: 711).

Pansin: Kung m

agsalita ka Tagalog, mga serbisyo ng tulong sa w

ika, nang walang bayad, ay m

agagamit sa

iyo. IA, IL, IN

, OH

: Tumaw

ag 1-800-965-4022, WA

: Tumaw

ag 1-877-750-3350 (TTY: 711).

،هابتنا

: اذإ

تنك

ملكتت

العربیة،

نإف

تامدخ

ةدعاسملا

ةيوغللا

ةرفوتم

كلناجما .

إيلینوي،

إنديانا،

وياهوأ:

صتال

مقرلاب

1-

800-

965-

4022

صتاف ىلع مقرلا )711ص يف عمسلا ل

صلا وأ ةبوعتنك يناعت نم مم

صتا مقرلاب :1-877-750-3350 (اذإ ةيالو نطنشاو :ل

A

ufmerksam

keit: Wenn Sie D

eutsch sprechen, Sprachassistenzdienste sind kostenlos, zur Verfügung. IA

, IL, IN

, OH

: Anruf 1-800-965-4022, W

A: A

nruf 1-877-750-3350 (TTY: 711).

ATTEN

TION

: Si vous parlez français, les services d'assistance linguistique, gratuitement, sont à votre

disposition. IA, IL, IN

, OH

: Appelez 1-800-965-4022, W

A: A

ppelez 1-877-750-3350 (TTY: 711).

ધયા: ત

મ વાત

તો �જરાત

ી, ભાષા સહાય

સવાઓ

, મફત

, તમારા મ

ાટ � ઉપલ�

છ. IA

, IL, IN, O

H: કૉલ

1-800-965-4022, W

A: કૉલ

1-877-750-3350 (TTY: 711).

注意:あなたは、日本語

、無料で言語支援サービスを、話す場合は、あなたに利用可能です。

1-800-965-4022 IA

, IL, IN, O

H: コ

ール

1-877-750-3350 WA

: コール(

TTY: 711)。

LET O

P: Als je spreekt pennsylvania nederlandse, taalkundige bijstand diensten, gratis voor u beschikbaar

zijn. IA, IL, IN

, OH

: Bel 1-800-965-4022, W

A: B

el 1-877-750-3350 (TTY: 711).

УВ

АГА

: Якщ

о ви говорите український, вставки послуги мовної допомоги, безкоштовно, доступні

для вас. IA, IL, IN

, OH

: Виклик 1-800-965-4022, W

A: В

иклик 1-877-750-3350 (TTY: 711).

ATTEN

ZION

E: Se si parla italiano, servizi di assistenza linguistica, a titolo gratuito, sono a vostra disposizione. IA

, IL, IN, O

H: C

hiamare 1-800-965-4022, W

A: C

hiamare 1-877-750-3350 (TTY

: 711). cm

p-nondiscrim15M

ED-0318